Case 199: Manual of CTO PCI: failure and complication

A patient was referred for PCI of a flush aorto-ostial CTO of the RCA. Given ostial occlusion location we tried a primary retrograde approach. Despite surfing and contrast-guided crossing attempts we could not cross several septal collaterals. A left main dissection was noted and successfully treated with left main stenting. Attempts to engage the RCA with several guide catheters failed. We considered the risk of attempting retrograde crossing via an epicardial small and tortuous collateral too high and stopped. The patient had an uneventful recovery.

[@shangz0216]

Thanks for the educative case presentation.

[@kathorhanes]

Scary case. I know attempting CTO requires a certain level of brave but this could have easily ended bad. Dissection of LM is visible from first run or high likelihood, and after stenting LM (requires dapt) and two (not one) septals „staining” there is even talk of continuing? Jesus… Cases like this need to keep us humble because the old rule is „primum non nocere”

[@kamkazihuan]

The left main dissection is evident in the first angiogram.

[@jansumbal9556]

Thank you very much for a nice case. My question is, why did you think that these symptoms (fatigue and exertional dyspnea) were equivalent for angina? I know you're high level in CTO PCI, but for me (and probably anywehre in our country - Slovakia) this patient would not be considered for CTO PCI treatement, because the risk outweights the potential benefits in this case. Did the patient have any comorbities, like AF, hypertension, any degree of diastolic dysfunction or higher LVEDP to be considered as HFpEF? If you will have the "same patient" in the future, what will your decisionbe? Thank you very much and good luck!

[@cchung1098]

Scaring !

[@farukakturk5388]

What do you do for septal staining?